Elite and Exclusive HSA preventive drug list

Effective January 1, 2021

Your employer has elected to include an HSA preventive drug coverage feature with your prescription benefit plan. Below is the list of medications available under your HSA preventive drug coverage. The actual cost of the medication will be applied toward the preventive benefit offered by your employer, allowing you to receive coverage even if you have not met your deductible. Benefits will be provided in accordance with U.S. Department of the Treasury and Internal Revenue Service (IRS) guidance with health spending accounts (HSAs) and qualified high deductible health plans (HDHPs).

The drugs listed below are grouped into broad categories. Each category includes an alphabetical list of drugs. Please verify with your plan if a generic drug must be tried before filling a brand version of a drug. Please refer to your benefit materials for coverage details and the plan website for current information as this publication is subject to change.

Key:

lowercase = generic  
UPPERCASE = BRAND  

Anti-coagulants/anti-platelets

Drug name

Dosage

anagrelide hcl cap


0.5 mg (Agrylin)

anagrelide hcl cap

1 mg

aspirin-dipyridamole cap er

12hr 25-200 mg (Aggrenox)

cilostazol tab

50 mg

cilostazol tab

100 mg

clopidogrel bisulfate tab

75 mg (base equiv)(Plavix)

clopidogrel bisulfate tab

300 mg (base equiv)

dipyridamole tab

25 mg

dipyridamole tab

50 mg

dipyridamole tab

75 mg

prasugrel hcl tab

5 mg (base equiv) (Effient)

prasugrel hcl tab

10 mg (base equiv) (Effient)

warfarin sodium tab

1 mg (Coumadin)

warfarin sodium tab

2 mg (Coumadin)

warfarin sodium tab

2.5 mg (Coumadin)

warfarin sodium tab

3 mg (Coumadin)

warfarin sodium tab

4 mg (Coumadin)

warfarin sodium tab

5 mg (Coumadin)

warfarin sodium tab

6 mg (Coumadin)

warfarin sodium tab

7.5 mg (Coumadin)

warfarin sodium tab

10 mg (Coumadin)

Bowel preparation

Drug name

Dosage

peg 3350-kcl-na bicarb-nacl-na sulfate for solution

236 gm (Golytely)

peg 3350-kcl-sod bicarb-nacl for solution

420 gm (Nulytely/flavor pack)

Breast cancer primary prevention

Drug name

Dosage

raloxifene hcl tab

60 mg (Evista)

tamoxifen citrate tab

10 mg (base equivalent)

tamoxifen citrate tab

20 mg (base equivalent)

Contraceptives

Barrier method types

Cervical caps

Drug name

Dosage

FEMCAP

cervical cap 22 mm

FEMCAP

cervical cap 26 mm

FEMCAP

cervical cap 30 mm

Diaphrams

Drug name

Dosage

CAYA

diaphragm arc-spring

OMNIFLEX DIAPHRAGM

diaphragms

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 60 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 65 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 70 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 75 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 80 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 85 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 90 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 95 mm

Female condom

Drug name

Dosage

FC FEMALE CONDOM

condoms - female

FC2 FEMALE CONDOM

condoms - female

Spermicide

Drug name

Dosage

ENCARE

nonoxynol-9 vaginal suppos 100 mg

OPTIONS GYNOL II VAGINAL

nonoxynol-9 gel 3% SHUR-SEAL – nonoxynol-9 gel 2%

VCF VAGINAL CONTRACEPTIVE

nonoxynol-9 film 28%

VCF VAGINAL CONTRACEPTIVE

nonoxynol-9 foam 12.5%

VCF Vaginal Contraceptive gel

nonoxynol-9 gel 4%

Sponge

Drug name

Dosage

TODAY SPONGE

nonoxynol-9 vaginal sponge 1000 mg

Emergency method types

Emergency Ella

Drug name

Dosage

ELLA

ulipristal acetate tab 30 mg

Emergency Progestin

Drug name

Dosage

Aftera - levonorgestrel tab

1.5 mg (Plan B One-Step)

Econtra Ez - levonorgestrel tab

1.5 mg (Plan B One-Step)

Econtra One-Step - levonorgestrel tab

1.5 mg (Plan B One-Step)

levonorgestrel tab

1.5 mg (Plan B One-Step)

My Choice - levonorgestrel tab

1.5 mg (Plan B One-Step)

My Way - levonorgestrel tab

1.5 mg (Plan B One-Step)

New Day - levonorgestrel tab

1.5 mg (Plan B One-Step)

Opcicon One-Step - levonorgestrel tab

1.5 mg (Plan B One-Step)

Option 2 - levonorgestrel tab

1.5 mg (Plan B One-Step)

Preventeza - levonorgestrel tab

1.5 mg (Plan B One-Step)

React - levonorgestrel tab

1.5 mg (Plan B One-Step)

Take Action - levonorgestrel tab

1.5 mg (Plan B One-Step)

Hormonal method types

Injectable Progestin

Drug name

Dosage

medroxyprogesterone acetate im susp

150 mg/ml (Depo-provera contrac)

medroxyprogesterone acetate im susp

prefilled syr 150 mg/ml (Depo-provera contrac))

Oral combined

Drug name

Dosage

Afirmelle - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Altavera - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Alyacen 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Alyacen 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Apri - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Aranelle - norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg

Aubra - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Aubra Eq - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Aurovela 1/20 - norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg (Loestrin 1/20-21)

Aurovela 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

Aurovela 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Aurovela Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Aurovela Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin Fe 1.5/30)

Aviane - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Ayuna - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Azurette - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Balziva - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Bekyree - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Blisovi 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Blisovi Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Blisovi Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin Fe 1.5/30)

Briellyn - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Caziant - desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg

Chateal - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Chateal Eq - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Cryselle-28 - norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Cyclafem 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Cyclafem 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Cyred - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Cyred Eq - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Dasetta 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Dasetta 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Delyla - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg (Beyaz)

drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg (Safyral)

Elinest - norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Emoquette - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Enpresse-28 - levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

Enskyce - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Estarylla - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

ethynodiol diacetate and ethinyl estradiol tab

1 mg-35 mcg

ethynodiol diacetate and ethinyl estradiol tab

1 mg-50 mcg

Falmina - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Femynor - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Gianvi - drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

Hailey 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

Hailey 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Isibloom - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Jasmiel - drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

Juleber - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Junel 1/20 - norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg (Loestrin 1/20-21)

Junel 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

Junel Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Junel Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin Fe 1.5/30)

Junel Fe 24 - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Kaitlib Fe - norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg (Generess Fe)

Kalliga - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Kariva - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Kelnor 1/35 - ethynodiol diacetate and ethinyl estradiol tab

1 mg-35 mcg

Kelnor 1/50 - ethynodiol diacetate and ethinyl estradiol tab

1 mg-50 mcg

Kurvelo - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Larin 1/20 - norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg (Loestrin 1/20-21)

Larin 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

Larin 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Larin Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Larin Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin Fe 1.5/30)

Larissia - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Layolis Fe - norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg (Generess Fe)

Leena - norethindrone-eth estradiol tab

0.5-35/1- 35/0.5-35 mg-mcg

Lessina - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Levonest - levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

Levora 0.15/30-28 - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Lillow - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Loryna - drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

Low-Ogestrel - norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Lo-Zumandimine - drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

Lutera - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Marlissa - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Melodetta 24 Fe - norethindrone ace-eth estradiol- fe chew tab

1 mg-20 mcg (24) (Minastrin 24 Fe)

Mibelas 24 Fe - norethindrone ace-eth estradiol-fe chew tab

1 mg-20 mcg (24) (Minastrin 24 Fe)

Microgestin 1/20 - norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg (Loestrin 1/20-21)

Microgestin 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

Microgestin Fe - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Microgestin Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin Fe 1.5/30)

Mili - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Mono-Linyah - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Necon 0.5/35-28 - norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

Nikki - drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

norethindrone and ethinyl estradiol-fe chew tab

0.4 mg-35 mcg

norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg (Generess Fe)

norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg (Loestrin 1/20-21)

norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin Fe 1.5/30)

norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

norethindrone ace-eth estradiol-fe chew tab

1 mg-20 mcg (24) (Minastrin 24 Fe)

norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Nortrel 0.5/35 (28) - norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

Nortrel 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Nortrel 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Ocella - drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

Orsythia - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Philith - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Pimtrea - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Pirmella 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Pirmella 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Portia-28 - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Previfem - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Reclipsen - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Simliya - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Sprintec 28 - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Sronyx - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Syeda - drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

Tarina 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Tarina Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Tarina Fe 1/20 Eq - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin Fe 1/20)

Tilia Fe - norethindrone ac-ethinyl estrad-fe tab

1-20/1-30/1-35 mg-mcg (Estrostep Fe)

Tri-Estarylla - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri Femynor - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri-Legest Fe - norethindrone ac-ethinyl estrad-fe tab

1-20/1-30/1-35 mg-mcg (Estrostep Fe)

Tri-Linyah - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri-Lo-Estarylla - norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Tri-Lo-Marzia - norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Tri-Lo-Mili - norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Tri-Lo-Sprintec - norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Tri-Mili - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri-Previfem - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri-Sprintec - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Trivora-28 - levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

Tri-Vylibra - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri-Vylibra Lo - norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Tydemy - drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg (Safyral)

Velivet - desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg

Vienva - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Viorele - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Volnea - desogest-eth estrad and ethinyl estrad tab

0.15-0.02/0.01 mg (21/5) (Mircette)

Vyfemla - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Vylibra - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Wera - norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

Wymzya Fe - norethindrone and ethinyl estradiol-fe chew tab

0.4 mg-35 mcg

Zarah - drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

Zovia 1/35E - ethynodiol diacetate and ethinyl estradiol tab

1 mg-35 mcg

Zumandimine - drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

Oral extended continuous

Drug name

Dosage

Amethia levonorg-eth est tab

0.15-0.03mg (84) and ethinyl est tab 0.01mg (7) (Seasonique)

Amethia Lo levonorg-eth est tab

0.1-0.02mg (84) and ethinyl est tab 0.01mg (7) (Loseasonique) Amethyst - levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg

Ashlyna levonorg-eth est tab

0.15-0.03mg (84) and ethinyl est tab 0.01mg (7) (Seasonique)

Camrese levonorg-eth est tab

0.15-0.03mg (84) and ethinyl est tab 0.01mg (7) (Seasonique)

Camrese Lo levonorg-eth est tab

0.1-0.02mg (84)and ethinyl est tab 0.01mg (7) (Loseasonique)

Daysee levonorg-eth est tab

0.15-0.03mg (84) and ethinyl est tab 0.01mg (7) (Seasonique)

Fayosim levonor-eth est tab

0.15-0.02/0.025/0.03 mg and ethinyl est 0.01 mg (Quartette)

Introvale levonorgestrel and ethinylinyl estradiol (91-day) tab

0.15-0.03 mg

Jaimiess levonorg-eth est tab

0.15-0.03mg (84) and ethinyl est tab 0.01mg (7) (Seasonique)

Jolessa levonorgestrel and ethinylinyl estradiol (91-day) tab

0.15-0.03 mg

levonorg-eth est tab 0.1-0.02mg (84)

ethinyl est tab 0.01mg (7) (Loseasonique)

levonorg-eth est tab 0.15-0.03mg (84)

ethinyl est tab 0.01mg (7) (Seasonique)

levonorgestrel and ethinylinyl estradiol (91-day) tab

0.15-0.03 mg

levonor-eth est tab 0.15-0.02/0.025/0.03 mg

ethinyl est 0.01 mg (Quartette)

levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg

Lojaimiess - levonorg-eth est tab 0.1-0.02mg (84)

eth est tab 0.01mg (7) (Loseasonique)

Rivelsa - levonor-eth est tab 0.15-0.02/0.025/0.03 mg

ethinyl est 0.01 mg (Quartette)

Setlakin

levonorgestrel and ethinyl estradiol (91-day) tab 0.15-0.03 mg

Simpesse - levonorg-eth est tab 0.15-0.03mg (84)

eth est tab 0.01mg (7) (Seasonique)

Oral progestin

Drug name

Dosage

Camila - norethindrone tab

0.35 mg (Ortho Micronor)

Deblitane - norethindrone tab

0.35 mg (Ortho Micronor)

Errin - norethindrone tab

0.35 mg (Ortho Micronor)

Heather - norethindrone tab

0.35 mg (Ortho Micronor)

Incassia - norethindrone tab

0.35 mg (Ortho Micronor)

Jencycla - norethindrone tab

0.35 mg (Ortho Micronor)

Lyza - norethindrone tab

0.35 mg (Ortho Micronor)

Nora-Be - norethindrone tab

0.35 mg (Ortho Micronor)

norethindrone tab

0.35 mg (Ortho Micronor)

Norlyda - norethindrone tab

0.35 mg (Ortho Micronor)

Norlyroc - norethindrone tab

0.35 mg (Ortho Micronor)

Sharobel - norethindrone tab

0.35 mg (Ortho Micronor)

Tulana - norethindrone tab

0.35 mg (Ortho Micronor)

Transdermal combine

Drug name

Dosage

XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr

Vaginal combined

Drug name

Dosage

NUVARING – etonogestrel-ethinyl estradiol va ring

0.120-0.015 mg/24hr

Diabetes medications

Insulin

Drug name

Dosage

FIASP – insulin aspart (with niacinamide) inj

100 unit/ml

FIASP FLEXTOUCH – insulin aspart (with niacinamide) sol pen-inj

100 unit/ml

FIASP PENFILL – insulin aspart (with niacinamide) solution cartridge

100 unit/ml

HUMULIN R U-500 (CONCENTRATED) – insulin regular (human) inj

500 unit/ml

HUMULIN R U-500 KWIKPEN – insulin regular (human) solution pen-injector

500 unit/ml

INSULIN ASPART – insulin aspart inj

100 unit/ml

INSULIN ASPART FLEXPEN – insulin aspart solution pen-injector

100 unit/ml

INSULIN ASPART PENFILL – insulin aspart solution cartridge

100 unit/ml

INSULIN ASPART PROTAMINE/ – insulin aspart prot and aspart (human) inj

100 unit/ml (70-30)

INSULIN ASPART PROTAMINE/ – insulin aspart prot and aspart sus pen-inj

100 unit/ml (70-30)

LANTUS – insulin glargine inj

100 unit/ml

LANTUS SOLOSTAR – insulin glargine solution pen- injector

100 unit/ml

LEVEMIR – insulin detemir inj

100 unit/ml

LEVEMIR FLEXTOUCH – insulin detemir solution pen- injector

100 unit/ml

NOVOLIN N – insulin nph (human) (isophane) inj

100 unit/ml

NOVOLIN N FLEXPEN – insulin nph (human) (isophane) susp pen-injector

100 unit/ml

NOVOLIN N FLEXPEN RELION – insulin nph (human) (isophane) susp pen-injector

100 unit/ml

NOVOLIN N RELION – insulin nph (human)(isophane) inj

100 unit/ml

NOVOLIN R – insulin regular (human) inj

100 unit/ml

NOVOLIN R FLEXPEN – insulin regular (human) solution pen-injector

100 unit/ml

NOVOLIN R FLEXPEN RELION – insulin regular (human) solution pen-injector

100 unit/ml

NOVOLIN R RELION – insulin regular (human) inj

100 unit/ml

NOVOLIN 70/30 – insulin nph isophane and regular human inj

100 unit/ml (70-30)

NOVOLIN 70/30 FLEXPEN – insulin nph and regular susp pen-inj

100 unit/ml (70-30)

NOVOLIN 70/30 FLEXPEN RELION – insulin nph and regular susp pen-inj

100 unit/ml (70-30)

NOVOLIN 70/30 RELION – insulin nph isophane and regular human inj

100 unit/ml (70-30)

NOVOLOG – insulin aspart inj

100 unit/ml

NOVOLOG FLEXPEN – insulin aspart solution pen-injector

100 unit/ml

NOVOLOG MIX 70/30 – insulin aspart prot and aspart(human) inj

100 unit/ml (70-30)

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot and aspart sus pen-inj

100 unit/ml (70-30)

NOVOLOG PENFILL – insulin aspart solution cartridge

100 unit/ml

TOUJEO MAX SOLOSTAR – insulin glargine solution pen-injector

300 unit/ml (2 unit dial)

TOUJEO SOLOSTAR – insulin glargine solution pen-injector

300 unit/ml (1 unit dial)

TRESIBA – insulin degludec inj

100 unit/ml

TRESIBA FLEXTOUCH – insulin degludec solution pen-injector

100 unit/ml

TRESIBA FLEXTOUCH – insulin degludec solution pen-injector

200 unit/ml

Oral

Drug name

Dosage

acarbose tab

25 mg (Precose)

acarbose tab

50 mg (Precose)

acarbose tab

100 mg (Precose)

glimepiride tab

1 mg (Amaryl)

glimepiride tab

2 mg (Amaryl)

glimepiride tab

4 mg (Amaryl)

glipizide tab

5 mg (Glucotrol)

glipizide tab

10 mg (Glucotrol)

glipizide tab er 24hr

2.5 mg (Glucotrol xl)

glipizide tab er 24hr

5 mg (Glucotrol xl)

glipizide tab er 24hr

10 mg (Glucotrol xl)

glipizide-metformin hcl tab

2.5-250 mg

glipizide-metformin hcl tab

2.5-500 mg

glipizide-metformin hcl tab

5-500 mg

glyburide micronized tab

1.5 mg (Glynase)

glyburide micronized tab

3 mg (Glynase)

glyburide micronized tab

6 mg (Glynase)

glyburide tab

1.25 mg

glyburide tab

2.5 mg

glyburide tab

5 mg

glyburide-metformin tab

1.25-250 mg

glyburide-metformin tab

2.5-500 mg

glyburide-metformin tab

5-500 mg

metformin hcl tab

500 mg

metformin hcl tab

850 mg

metformin hcl tab

1000 mg

metformin hcl tab er

24hr 500 mg

metformin hcl tab er

24hr 750 mg

miglitol tab

25 mg (Glyset)

miglitol tab

50 mg (Glyset)

miglitol tab

100 mg (Glyset)

nateglinide tab

60 mg (Starlix)

nateglinide tab

120 mg (Starlix)

pioglitazone hcl tab

15 mg (base equiv) (Actos)

pioglitazone hcl tab

30 mg (base equiv) (Actos)

pioglitazone hcl tab

45 mg (base equiv) (Actos)

pioglitazone hcl-metformin hcl tab

15-500 mg (Actoplus met)

pioglitazone hcl-metformin hcl tab

15-850 mg (Actoplus met)

repaglinide tab

0.5 mg

repaglinide tab

1 mg

repaglinide tab

2 mg

Diabetic supplies

Basic

Drug name

Dosage

Calibration liquid

BAYER CONTOUR, BAYER CONTOUR NEXT

Insulin syringes

 

Lancets

 

Lancet devices

 

Pen Needles

 

Test strips and discs

BAYER CONTOUR, BAYER CONTOUR NEXT

Fluoride

Dental products and combinations

Drug name

Dosage

sodium fluoride cream

1.1%(Prevident 5000 plus)

sodium fluoride gel

1.1% (0.5% f)(Prevident fluoride)

sodium fluoride paste

1.1%(Prevident 5000 boost)

sodium fluoride rinse

0.2% (Prevident)

sodium fluoride-potassium nitrate paste

1.1-5%(Prevident 5000 sensi)

stannous fluoride conc

0.63%

stannous fluoride gel

0.4% (Gel-Kam)

Supplements and combinations

Drug name

Dosage

sodium fluoride chew tab

0.25 mg f (from 0.55 mg naf)

sodium fluoride chew tab

0.5 mg f (from 1.1 mg naf)

sodium fluoride chew tab

1 mg f (from 2.2 mg naf)

sodium fluoride solution

0.125 mg/drop f (0.275 mg/drop naf)

sodium fluoride solution

0.5 mg/ml f (from 1.1 mg/ml naf)

High blood pressure

Drug name

Dosage

acebutolol hcl cap

200 mg

acebutolol hcl cap

400 mg

amiloride hcl tab

5 mg

amiloride and hydrochlorothiazide tab

5-50 mg

amlodipine besylate tab

2.5 mg (base equivalent)(Norvasc)

amlodipine besylate tab

5 mg (base equivalent) (Norvasc)

amlodipine besylate tab

10 mg (base equivalent) (Norvasc)

amlodipine besylate-benazepril hcl cap

2.5-10 mg

amlodipine besylate-benazepril hcl cap

5-10 mg (Lotrel)

amlodipine besylate-benazepril hcl cap

5-20 mg (Lotrel)

amlodipine besylate-benazepril hcl cap

5-40 mg

amlodipine besylate-benazepril hcl cap

10-20 mg (Lotrel)

amlodipine besylate-benazepril hcl cap

10-40 mg (Lotrel)

amlodipine besylate-olmesartan medoxomil tab

5-20 mg (Azor)

amlodipine besylate-olmesartan medoxomil tab

5-40 mg (Azor)

amlodipine besylate-olmesartan medoxomil tab

10-20 mg (Azor)

amlodipine besylate-olmesartan medoxomil tab

10-40 mg (Azor)

amlodipine besylate-valsartan tab

5-160 mg (Exforge)

amlodipine besylate-valsartan tab

5-320 mg (Exforge)

amlodipine besylate-valsartan tab

10-160 mg (Exforge)

amlodipine besylate-valsartan tab

10-320 mg (Exforge)

amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg (Exforge hct)

amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg (Exforge hct)

amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg (Exforge hct)

amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg (Exforge hct)

amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg (Exforge hct)

atenolol tab

25 mg (Tenormin)

atenolol tab

50 mg (Tenormin)

atenolol tab

100 mg (Tenormin)

atenolol and chlorthalidone tab

50-25 mg (Tenoretic 50)

atenolol and chlorthalidone tab

100-25 mg (Tenoretic 100)

benazepril hcl tab

5 mg

benazepril hcl tab

10 mg (Lotensin)

benazepril hcl tab

20 mg (Lotensin)

benazepril hcl tab

40 mg (Lotensin)

benazepril and hydrochlorothiazide tab

5-6.25 mg

benazepril and hydrochlorothiazide tab

10-12.5 mg (Lotensin hct)

benazepril and hydrochlorothiazide tab

20-12.5 mg (Lotensin hct)

benazepril and hydrochlorothiazide tab

20-25 mg (Lotensin hct)

betaxolol hcl tab

10 mg

betaxolol hcl tab

20 mg

bisoprolol fumarate tab

5 mg

bisoprolol fumarate tab

10 mg

bisoprolol and hydrochlorothiazide tab

2.5-6.25 mg (Ziac)

bisoprolol and hydrochlorothiazide tab

5-6.25 mg (Ziac)

bisoprolol and hydrochlorothiazide tab

10-6.25 mg (Ziac)

bumetanide tab

0.5 mg (Bumex)

bumetanide tab

1 mg (Bumex)

bumetanide tab

2 mg (Bumex)

candesartan cilexetil tab

4 mg (Atacand)

candesartan cilexetil tab

8 mg (Atacand)

candesartan cilexetil tab

16 mg (Atacand)

candesartan cilexetil tab

32 mg (Atacand)

candesartan cilexetil-hydrochlorothiazide tab

16-12.5 mg (Atacand hct)

candesartan cilexetil-hydrochlorothiazide tab

32-12.5 mg (Atacand hct)

candesartan cilexetil-hydrochlorothiazide tab

32-25 mg (Atacand hct)

captopril tab

12.5 mg

captopril tab

25 mg

captopril tab

50 mg

captopril tab

100 mg

carvedilol tab

3.125 mg (Coreg)

carvedilol tab

6.25 mg (Coreg)

carvedilol tab

12.5 mg (Coreg)

carvedilol tab

25 mg (Coreg)

chlorthalidone tab

25 mg

chlorthalidone tab

50 mg

clonidine hcl tab

0.1 mg (Catapres)

clonidine hcl tab

0.2 mg (Catapres)

clonidine hcl tab

0.3 mg (Catapres)

clonidine td patch weekly

0.1 mg/24hr (Catapres-tts-1)

clonidine td patch weekly

0.2 mg/24hr (Catapres-tts-2)

clonidine td patch weekly

0.3 mg/24hr (Catapres-tts-3)

diltiazem hcl tab

30 mg (Cardizem)

diltiazem hcl tab

60 mg (Cardizem)

diltiazem hcl tab

90 mg

diltiazem hcl tab

120 mg (Cardizem)

diltiazem hcl cap er

12hr 60 mg

diltiazem hcl cap er

12hr 90 mg

diltiazem hcl cap er 12hr

120 mg

diltiazem hcl coated beads cap er 24hr

120 mg (Cardizem cd)

diltiazem hcl coated beads cap er 24hr

180 mg (Cardizem cd)

diltiazem hcl coated beads cap er 24hr

240 mg (Cardizem cd)

diltiazem hcl coated beads cap er 24hr

300 mg (Cardizem cd)

diltiazem hcl coated beads cap er 24hr

360 mg (Cardizem cd)

diltiazem hcl coated beads tab er 24hr

180 mg (Cardizem la)

diltiazem hcl coated beads tab er 24hr

240 mg (Cardizem la)

diltiazem hcl coated beads tab er 24hr

300 mg (Cardizem la)

diltiazem hcl coated beads tab er 24hr

360 mg (Cardizem la)

diltiazem hcl coated beads tab er 24hr

420 mg (Cardizem la)

diltiazem hcl extended release beads cap er 24hr

120 mg (Tiazac)

diltiazem hcl extended release beads cap er 24hr

180 mg (Tiazac)

diltiazem hcl extended release beads cap er 24hr

240 mg (Tiazac)

diltiazem hcl extended release beads cap er 24hr

300 mg (Tiazac)

diltiazem hcl extended release beads cap er 24hr

360 mg (Tiazac)

diltiazem hcl extended release beads cap er 24hr

420 mg (Tiazac)

doxazosin mesylate tab

1 mg (Cardura)

doxazosin mesylate tab

2 mg (Cardura)

doxazosin mesylate tab

4 mg (Cardura)

doxazosin mesylate tab

8 mg (Cardura)

enalapril maleate tab

2.5 mg (Vasotec)

enalapril maleate tab

5 mg (Vasotec)

enalapril maleate tab

10 mg (Vasotec)

enalapril maleate tab

20 mg (Vasotec)

enalapril maleate and hydrochlorothiazide tab

5-12.5 mg

enalapril maleate and hydrochlorothiazide tab

10-25 mg (Vaseretic)

eplerenone tab

25 mg (Inspra)

eplerenone tab

50 mg (Inspra)

felodipine tab er 24hr

2.5 mg

felodipine tab er 24hr

5 mg

felodipine tab er 24hr

10 mg

fosinopril sodium and hydrochlorothiazide tab

10-12.5 mg

fosinopril sodium and hydrochlorothiazide tab

20-12.5 mg

fosinopril sodium tab

10 mg

fosinopril sodium tab

20 mg

fosinopril sodium tab

40 mg

furosemide oral solution

10 mg/ml

furosemide tab

20 mg (Lasix)

furosemide tab

40 mg (Lasix)

furosemide tab

80 mg (Lasix)

guanfacine hcl tab

1 mg

guanfacine hcl tab

2 mg

hydralazine hcl tab

10 mg

hydralazine hcl tab

25 mg

hydralazine hcl tab

50 mg

hydralazine hcl tab

100 mg

hydrochlorothiazide cap

12.5 mg

hydrochlorothiazide tab

12.5 mg

hydrochlorothiazide tab

25 mg

hydrochlorothiazide tab

50 mg

indapamide tab

1.25 mg

indapamide tab

2.5 mg

irbesartan tab

75 mg (Avapro)

irbesartan tab

150 mg (Avapro)

irbesartan tab

300 mg (Avapro)

irbesartan-hydrochlorothiazide tab

150-12.5 mg (Avalide)

irbesartan-hydrochlorothiazide tab

300-12.5 mg (Avalide)

isradipine cap

2.5 mg

isradipine cap

5 mg

labetalol hcl tab

100 mg

labetalol hcl tab

200 mg

labetalol hcl tab

300 mg

lisinopril tab

2.5 mg (Zestril)

lisinopril tab

5 mg (Zestril)

lisinopril tab

10 mg (Prinivil)

lisinopril tab

20 mg (Prinivil)

lisinopril tab

30 mg (Zestril)

lisinopril tab

40 mg (Zestril)

lisinopril and hydrochlorothiazide tab

10-12.5 mg (Zestoretic)

lisinopril and hydrochlorothiazide tab

20-12.5 mg (Zestoretic)

lisinopril and hydrochlorothiazide tab

20-25 mg (Zestoretic)

losartan potassium tab

25 mg (Cozaar)

losartan potassium tab

50 mg (Cozaar)

losartan potassium tab

100 mg (Cozaar)

losartan potassium and hydrochlorothiazide tab

50-12.5 mg (Hyzaar)

losartan potassium and hydrochlorothiazide tab

100-12.5 mg (Hyzaar)

losartan potassium and hydrochlorothiazide tab

100-25 mg (Hyzaar)

methyldopa tab

250 mg

methyldopa tab

500 mg

metolazone tab

2.5 mg

metolazone tab

5 mg

metolazone tab

10 mg

metoprolol and hydrochlorothiazide tab

50-25 mg (Lopressor hct)

metoprolol and hydrochlorothiazide tab

100-25 mg

metoprolol succinate tab er 24hr

25 mg (tartrate equiv) (Toprol xl)

metoprolol succinate tab er 24hr

50 mg (tartrate equiv) (Toprol xl)

metoprolol succinate tab er 24hr

100 mg (tartrate equiv) (Toprol xl)

metoprolol succinate tab er 24hr

200 mg (tartrate equiv) (Toprol xl)

metoprolol tartrate tab

25 mg

metoprolol tartrate tab

37.5 mg

metoprolol tartrate tab

50 mg (Lopressor)

metoprolol tartrate tab

75 mg

metoprolol tartrate tab

100 mg (Lopressor)

minoxidil tab

2.5 mg

minoxidil tab

10 mg

moexipril hcl tab

7.5 mg

moexipril hcl tab

15 mg

nadolol tab

20 mg (Corgard)

nadolol tab

40 mg (Corgard)

nadolol tab

80 mg (Corgard)

nicardipine hcl cap

20 mg

nicardipine hcl cap

30 mg

nifedipine cap

10 mg (Procardia)

nifedipine cap

20 mg

nifedipine tab er 24hr

30 mg

nifedipine tab er 24hr

60 mg

nifedipine tab er 24hr

90 mg

nifedipine tab er 24hr

osmotic release 30 mg (Procardia xl)

nifedipine tab er 24hr

osmotic release 60 mg (Procardia xl)

nifedipine tab er 24hr

osmotic release 90 mg (Procardia xl)

olmesartan medoxomil tab

5 mg (Benicar)

olmesartan medoxomil tab

20 mg (Benicar)

olmesartan medoxomil tab

40 mg (Benicar)

olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg (Benicar hct)

olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg (Benicar hct)

olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg (Benicar hct)

olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg (Tribenzor)

olmesartan-amlodipine-hydrochlorothiazide tab

40-5-12.5 mg (Tribenzor)

olmesartan-amlodipine-hydrochlorothiazide tab

40-5-25 mg (Tribenzor)

olmesartan-amlodipine-hydrochlorothiazide tab

40-10-12.5 mg (Tribenzor)

olmesartan-amlodipine-hydrochlorothiazide tab

40-10-25 mg (Tribenzor)

perindopril erbumine tab

2 mg

perindopril erbumine tab

4 mg

perindopril erbumine tab

8 mg

phenoxybenzamine hcl cap

10 mg (Dibenzyline)

pindolol tab

5 mg

pindolol tab

10 mg

prazosin hcl cap

1 mg (Minipress)

prazosin hcl cap

2 mg (Minipress)

prazosin hcl cap

5 mg (Minipress)

propranolol hcl cap er 24hr

60 mg (Inderal la)

propranolol hcl cap er 24hr

80 mg (Inderal la)

propranolol hcl cap er 24hr

120 mg (Inderal la)

propranolol hcl cap er 24hr

160 mg (Inderal la)

propranolol hcl tab

10 mg

propranolol hcl tab

20 mg

propranolol hcl tab

40 mg

propranolol hcl tab

60 mg

propranolol hcl tab

80 mg

quinapril hcl tab

5 mg (Accupril)

quinapril hcl tab

10 mg (Accupril)

quinapril hcl tab

20 mg (Accupril)

quinapril hcl tab

40 mg (Accupril)

quinapril-hydrochlorothiazide tab

10-12.5 mg (Accuretic)

quinapril-hydrochlorothiazide tab

20-12.5 mg (Accuretic)

quinapril-hydrochlorothiazide tab

20-25 mg (Accuretic)

ramipril cap

1.25 mg (Altace)

ramipril cap

2.5 mg (Altace)

ramipril cap

5 mg (Altace)

ramipril cap

10 mg (Altace)

spironolactone tab

25 mg (Aldactone)

spironolactone tab

50 mg (Aldactone)

spironolactone tab

100 mg (Aldactone)

spironolactone and hydrochlorothiazide tab

25-25 mg (Aldactazide)

telmisartan tab

20 mg (Micardis)

telmisartan tab

40 mg (Micardis)

telmisartan tab

80 mg (Micardis)

telmisartan-amlodipine tab

40-5 mg (Twynsta)

telmisartan-amlodipine tab

40-10 mg (Twynsta)

telmisartan-amlodipine tab

80-5 mg (Twynsta)

telmisartan-amlodipine tab

80-10 mg (Twynsta)

telmisartan-hydrochlorothiazide tab

40-12.5 mg (Micardis hct)

telmisartan-hydrochlorothiazide tab

80-12.5 mg (Micardis hct)

telmisartan-hydrochlorothiazide tab

80-25 mg (Micardis hct)

terazosin hcl cap

1 mg (base equivalent)

terazosin hcl cap

2 mg (base equivalent)

terazosin hcl cap

5 mg (base equivalent)

terazosin hcl cap

10 mg (base equivalent)

torsemide tab

5 mg

torsemide tab

10 mg

torsemide tab

20 mg

torsemide tab

100 mg

trandolapril tab

1 mg

trandolapril tab

2 mg

trandolapril tab

4 mg

trandolapril-verapamil hcl tab er

2-180 mg (Tarka)

trandolapril-verapamil hcl tab er

2-240 mg (Tarka)

trandolapril-verapamil hcl tab er

4-240 mg (Tarka)

triamterene cap

50 mg (Dyrenium)

triamterene cap

100 mg (Dyrenium)

triamterene and hydrochlorothiazide cap

37.5-25 mg (Dyazide)

triamterene and hydrochlorothiazide tab

37.5-25 mg (Maxzide-25)

triamterene and hydrochlorothiazide tab

75-50 mg (Maxzide)

valsartan tab

40 mg (Diovan)

valsartan tab

80 mg (Diovan)

valsartan tab

160 mg (Diovan)

valsartan tab

320 mg (Diovan)

valsartan-hydrochlorothiazide tab

80-12.5 mg (Diovan hct)

valsartan-hydrochlorothiazide tab

160-12.5 mg (Diovan hct)

valsartan-hydrochlorothiazide tab

160-25 mg (Diovan hct)

valsartan-hydrochlorothiazide tab

320-12.5 mg (Diovan hct)

valsartan-hydrochlorothiazide tab

320-25 mg (Diovan hct)

verapamil hcl cap er

24hr 120 mg (Verelan)

verapamil hcl cap er 24hr

180 mg (Verelan)

verapamil hcl cap er 24hr

240 mg (Verelan)

verapamil hcl tab

40 mg

verapamil hcl tab

80 mg

verapamil hcl tab

120 mg

verapamil hcl tab er

120 mg (Calan sr)

verapamil hcl tab er

180 mg (Calan sr)

verapamil hcl tab er

240 mg (Calan sr)

High Cholesterol

Drug name

Dosage

atorvastatin calcium tab

10 mg (base equivalent)(Lipitor)

atorvastatin calcium tab

20 mg (base equivalent)(Lipitor)

atorvastatin calcium tab

40 mg (base equivalent)(Lipitor)

atorvastatin calcium tab

80 mg (base equivalent)(Lipitor)

cholestyramine light powder

4 gm/dose (Questran light

cholestyramine light powder packets

4 gm

cholestyramine powder

4 gm/dose (Questran)

cholestyramine powder packets

4 gm (Questran)

choline fenofibrate cap dr

45 mg (fenofibric acid equiv) (Trilipix)

colesevelam hcl packet for susp

3.75 gm (Welchol)

colesevelam hcl tab

625 mg (Welchol)

colestipol hcl granules

5 gm (Colestid)

colestipol hcl granule packets

5 gm (Colestid)

colestipol hcl tab

1 gm (Colestid)

ezetimibe tab

10 mg (Zetia)

ezetimibe-simvastatin tab

10-10 mg (Vytorin)

ezetimibe-simvastatin tab

10-20 mg (Vytorin)

ezetimibe-simvastatin tab

10-40 mg (Vytorin)

ezetimibe-simvastatin tab

10-80 mg (Vytorin)

fenofibrate micronized cap

43 mg

fenofibrate micronized cap

67 mg

fenofibrate micronized cap

134 mg

fenofibrate micronized cap

200 mg

fenofibrate tab

48 mg (Tricor)

fenofibrate tab

54 mg

fenofibrate tab

145 mg (Tricor)

fenofibrate tab

160 mg

gemfibrozil tab

600 mg (Lopid)

lovastatin tab

10 mg

lovastatin tab

20 mg

lovastatin tab

40 mg

niacin tab er

500 mg (antihyperlipidemic) (Niaspan)

niacin tab er

750 mg (antihyperlipidemic) (Niaspan)

niacin tab er

1000 mg (antihyperlipidemic)(Niaspan)

pravastatin sodium tab

10 mg

pravastatin sodium tab

20 mg (Pravachol)

pravastatin sodium tab

40 mg (Pravachol)

pravastatin sodium tab

80 mg

rosuvastatin calcium tab

5 mg (Crestor)

rosuvastatin calcium tab

10 mg (Crestor)

rosuvastatin calcium tab

20 mg (Crestor)

rosuvastatin calcium tab

40 mg (Crestor)

simvastatin tab

5 mg

simvastatin tab

10 mg (Zocor)

simvastatin tab

20 mg (Zocor)

simvastatin tab

40 mg (Zocor)

simvastatin tab

80 mg (Zocor)

Osteoporosis

Drug name

Dosage

alendronate sodium tab

10 mg

alendronate sodium tab

35 mg

alendronate sodium tab

70 mg (Fosamax)

calcitonin (salmon) nasal solution

200 unit/act

ibandronate sodium tab

150 mg (base equivalent) (Boniva)

raloxifene hcl tab

60 mg (Evista)

risedronate sodium tab

150 mg (Actonel)

risedronate sodium tab

30 mg (Actonel)

risedronate sodium tab

35 mg (Actonel)

risedronate sodium tab

5 mg (Actonel)

risedronate sodium tab delayed release

35 mg (Atelvia)

Respiratory

Medications

Drug name

Dosage

acetylcysteine inhalation solution

10%

acetylcysteine inhalation solution

20%

ADVAIR DISKUS – fluticasone-salmeterol aerosol powder ba

100-50 mcg/dose

ADVAIR DISKUS – fluticasone-salmeterol aerosol powder ba

250-50 mcg/dose

ADVAIR DISKUS – fluticasone-salmeterol aerosol powder ba

500-50 mcg/dose

ADVAIR HFA – fluticasone-salmeterol inhalation aerosol

45-21 mcg/act

ADVAIR HFA – fluticasone-salmeterol inhalation aerosol

115-21 mcg/act

ADVAIR HFA – fluticasone-salmeterol inhalation aerosol

230-21 mcg/act

albuterol sulfate inhalation aerosolo

108 mcg/act (90mcg base equiv) (Proair hfa)

albuterol sulfate solution nebulizer

0.083% (2.5 mg/3ml)

albuterol sulfate solution nebulizer

0.5% (5 mg/ml)

albuterol sulfate solution nebulizer

0.63 mg/3ml (base equiv)

albuterol sulfate solution nebulizer

1.25 mg/3ml (base equiv)

albuterol sulfate syrup

2 mg/5ml

albuterol sulfate tab

2 mg

albuterol sulfate

tab 4 mg

ANORO ELLIPTA – umeclidinium-vilanterol aerosolo powder ba

62.5-25 mcg/inh

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activated

50 mcg/act

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activated

100 mcg/act

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activated

200 mcg/act

ASMANEX HFA – mometasone furoate inhalation aerosol suspension

50 mcg/act

ASMANEX HFA – mometasone furoate inhalation aerosol suspension

100 mcg/act

ASMANEX HFA – mometasone furoate inhalation aerosol suspension

200 mcg/act

ASMANEX TWISTHALER 30 MET

mometasone furoate inhalation powder 110 mcg/inh (breath activated)

ASMANEX TWISTHALER 30 MET

mometasone furoate inhalation powder 220 mcg/inh (breath activated)

ASMANEX TWISTHALER 60 MET

mometasone furoate inhalation powder 220 mcg/inh (breath activated)

ASMANEX TWISTHALER 120 ME

mometasone furoate inhalation powder 220 mcg/inh (breath activated)

BREO ELLIPTA

fluticasone furoate-vilanterol aerosolo powder ba 100-25 mcg/inh

BREO ELLIPTA

fluticasone furoate-vilanterol aerosolo powder ba 200-25 mcg/inh

BREZTRI AERO SPHERE

budesonide- glycopyrrolate-formoterol aerosols 160-9-4.8 mcg/act

BROVANA – arformoterol tartrate solution nebulizer

15 mcg/2ml (base equiv)

budesonide inhalation susp

0.25 mg/2ml (Pulmicort)

budesonide inhalation susp

0.5 mg/2ml (Pulmicort)

budesonide inhalation susp

1 mg/2ml (Pulmicort)

cromolyn sodium solution nebulizer

20 mg/2ml

DULERA – mometasone furoate-formoterol fumarate aerosol

50-5 mcg/act

DULERA – mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act

DULERA – mometasone furoate-formoterol fumarate aerosol

200-5 mcg/act

FLOVENT DISKUS – fluticasone propionate aerosol powderder ba

50 mcg/blister

FLOVENT DISKUS – fluticasone propionate aerosol powderder ba

100 mcg/blister

FLOVENT DISKUS – fluticasone propionate aerosol powderder ba

250 mcg/blister

FLOVENT HFA – fluticasone propionate hfa inhalation aerosol

44 mcg/act (50/valve)

FLOVENT HFA – fluticasone propionate hfa inhalation aerosol

110 mcg/act (125/valve)

FLOVENT HFA – fluticasone propionate hfa inhalation aerosol

220 mcg/act (250/valve)

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aerosol powder ba

55-14 mcg/act

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aerosol powder ba

113-14 mcg/act

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aerosol powder ba

232-14 mcg/act

INCRUSE ELLIPTA – umeclidinium br aerosolo powder breath act

62.5 mcg/inh (base eq)

ipratropium bromide inhalation solution

0.02%

ipratropium-albuterol nebulizer solution

0.5-2.5(3) mg/3ml

levalbuterol hcl solution nebulizer

0.31 mg/3ml (base equiv) (Xopenex)

levalbuterol hcl solution nebulizer

0.63 mg/3ml (base equiv) (Xopenex)

levalbuterol hcl solution nebulizer

1.25 mg/3ml (base equiv) (Xopenex)

levalbuterol hcl solution nebulizer conc

1.25 mg/0.5ml (base equiv) (Xopenex concentrate)

montelukast sodium chew tab

4 mg (base equiv) (Singulair)

montelukast sodium chew tab

5 mg (base equiv) (Singulair)

montelukast sodium tab

10 mg (base equiv)(Singulair)

QVAR REDIHALER – beclomethasone diprop hfa breath act inh aerosol

40 mcg/act

QVAR REDIHALER – beclomethasone diprop hfa breath act inh aerosol

80 mcg/act

SEREVENT DISKUS – salmeterol xinafoate aerosol powderder ba

50 mcg/dose (base equiv)

SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhalation cap

18 mcg (base equiv)

SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhalation aerosol

1.25 mcg/act

SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhalation aerosol

2.5 mcg/act

STIOLTO RESPIMAT – tiotropium br-olodaterol inhalation aerosol solution

2.5-2.5 mcg/act

STRIVERDI RESPIMAT – olodaterol hcl inhalation aerosol solution

2.5 mcg/act (base equiv)

SYMBICORT – budesonide-formoterol fumarate dihyd aerosol

80-4.5 mcg/act

SYMBICORT – budesonide-formoterol fumarate dihyd aerosol

160-4.5 mcg/act

terbutaline sulfate tab

2.5 mg

terbutaline sulfate tab

5 mg

theophylline solution

80 mg/15ml

theophylline tab er

24hr 400 mg

theophylline tab er

24hr 600 mg

TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh

VENTOLIN HFA – albuterol sulfate inhalation aerosol

108 mcg/act (90mcg base equiv)

zafirlukast tab

10 mg (Accolate)

zafirlukast tab

20 mg (Accolate)

Tobacco cessation

Drug name

Dosage

Brand/generic OTC nicotine gum, lozenges, patches

 

Brand/generic Rx nicotine gum, lozenges, patches

 

bupropion hcl (smoking deterrent) tab er

12hr 150 mg

CHANTIX – varenicline tartrate tab

0.5 mg (base equiv)

CHANTIX – varenicline tartrate tab

1 mg (base equiv)

CHANTIX CONTINUING MONTH – varenicline tartrate tab

1 mg (base equiv)

CHANTIX STARTING MONTH PACK – varenicline tartrate tab

0.5 mg x 11 and tab 1 mg x 42 pack

NICOTINE TRANSDERMAL SYSTEM – nicotine td patch

24 hr kit 21-14-7 mg/24hr

NICOTROL INHALER – nicotine inhaler system

10 mg (4 mg delivered)

NICOTROL NS – nicotine nasal spray

10 mg/ml (0.5 mg/spray)

Vaccines

Drug name

Dosage

ACTHIB – haemophilus b polysaccharide conjugate vaccine for inj

 

ADACEL – tet tox-diph-acell pertuss ad inj

5-2-15.5 lf-lf-mcg/0.5ml

AFLURIA QUADRIVALENT – influenza virus vaccine split quadrivalent im inj

 

AFLURIA QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr

0.25 ml

AFLURIA QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr

0.5ml

BEXSERO – meningococcal vac b (recomb omv adjuv) inj prefilled syringe

 

BOOSTRIX – tet tox-diph-acell pertuss ad inj

5-2.5-18.5 lf-lf-mcg/0.5ml

DAPTACEL – diph, acellular pert and tet tox inj

15 lf-23 mcg-5 lf/0.5ml

DIPHTHERIA/TETANUS TOXOID – diphtheria-tetanus tox adsorbed (dt) im inj

25-5 unit/0.5ml

ENGERIX-B – hepatitis b vaccine (recombinant)

10 mcg/0.5ml

ENGERIX-B – hepatitis b vaccine (recombinant)

20 mcg/ml

ENGERIX-B – hepatitis b vaccine (recombinant) susp

10 mcg/0.5ml

ENGERIX-B – hepatitis b vaccine (recombinant) susp

20 mcg/ml

FLUAD – influenza vac type a&b surface ant adj susp pref syr

0.5 ml

FLUAD QUADRIVALENT – influenza vac type a and b surface ant adj quad pref syr

0.5 ml

FLUARIX QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr

0.5ml

FLUBLOK QUADRIVALENT – influenza vac recomb ha quad pf solution pref syr

0.5 ml

FLUCELVAX QUADRIVALENT – influenza vac tissue-cultured subunit quadrivalent im susp

 

FLUCELVAX QUADRIVALENT – influenza vac tiss-cult subunt quad susp pref syr

0.5 ml

FLULAVAL QUADRIVALENT – influenza virus vaccine split quadrivalent im inj

 

FLULAVAL QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr

0.5ml

FLUZONE HIGH-DOSE PF – influenza virus vac split high-dose pf susp pref syr

0.5ml

FLUZONE HIGH-DOSE PF – influenza vac split high- dose quad pf susp pref syr

0.7 ml

FLUZONE QUADRIVALENT – influenza virus vaccine split quadrivalent im inj

 

FLUZONE QUADRIVALENT – influenza virus vaccine split quadrivalent inj

0.5 ml

FLUZONE QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr

0.25 ml

FLUZONE QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr

0.5ml

GARDASIL 9 – human papillomavirus (hpv) 9-valent lit recomb vac im susp

 

GARDASIL 9 – human papillomavirus (hpv) 9-valent recomb vac susp pref syr

 

HAVRIX – hepatitis a vaccine inj susp

720 el -valent unit/0.5ml

HAVRIX – hepatitis a vaccine inj susp

1440 el unit/ml

HEPLISAV-B – hepatitis b vaccine recomb adjuvanted pref syr

20 mcg/0.5ml

HIBERIX – haemophilus b polysaccharide conjugate d vac for inj

10 mcg

INFANRIX – diph, acellular pert and tet tox inj

25 lf-ate 58 mcg-10 lf/0.5ml

IPOL INACTIVATED IPV – poliovirus vaccine, ipv injection

 

KINRIX – diph-tetanus tox ad-acell pert and polio virus, ipv vac inj

 

M-M-R II – measles-mumps-rubella virus vaccines for inj solution

 

MENACTRA – meningococcal (a, c, y, and w-135) for conjugate vaccine inj

 

MENQUADFI – meningococcal (a, c, y, and w-135) conjugate vaccine inj

 

MENVEO – meningococcal (a, c, y, and w-135) oligo conj vac for inj

 

PEDIARIX – diph-tetanus tox-acell pert-hepatitis b-go polio ipv vac inj

 

PEDVAX HIB – haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml

PENTACEL – diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp

 

PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj

25 mcg/0.5ml

PNEUMOVAX 23/1 DOSE – pneumococcal vaccine nt polyvalent inj

25 mcg/0.5ml

PREVNAR 13 – pneumococcal 13-valent conjugate vaccine inj

 

PROQUAD – measles-mumps-rubella-varicella virus vaccines for susp

 

QUADRACEL – diph-tetanus tox ad-acell pert and polio virus, ipv vac inj

 

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

10 mcg/ml

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

40 mcg/ml

ROTARIX – rotavirus vaccine, live for oral susp

 

ROTATEQ – rotavirus vaccine, live oral pentavalent solution

 

SHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml

TDVAX - tetanus-diphtheria toxoids (td) inj

2-2 lf/0.5ml

TENIVAC – tetanus-diphtheria toxoids (td) inj

5-2 lfu

TRUMENBA – meningococcal group b vac (recomb) im susp prefilled syr

 

TWINRIX – hep a-hep b vaccine susp pref syr

720-20 elu-mcg/ml

VAQTA – hepatitis a vaccine inj susp

25 unit/0.5ml

VAQTA – hepatitis a vaccine inj susp

50 unit/ml

VARIVAX – varicella virus vac live for subcutaneous inj

1350 pfu/0.5ml

ZOSTAVAX – zoster vaccine live for subcutaneous susp

19400 unit/0.65ml